II.

NURSING CARE PLANS

Assessment Nursing Scientific Planning Interventions Rationale Evaluation
Diagnosis Inference
Subjective cues: Impaired Skin Circulatory Short-term: Independent: Short-term:
- “My wound Integrity related impairment In 24 hours, - Assess any - Increase in In 24 hours,
cannot heal. I got to circulatory caused by the lesion will changes in body body lesion had
it yesterday and impairment high glucose display signs of temperature temperature is a displayed signs
immediately secondary to levels that stiffen healing from manifestation of of healing as
went to check on Diabetes the blood diameter of 3cm an inflammation evidenced by the
it after I noticed Mellitus as vessels, to 2.5cm. and may also decreased
it today.” evidenced by decreasing the indicate diameter of the
ineffective ability to Long-term: presence of lesion from 3cm
Objective cues: wound healing regulate pathway During stay in infection. to 2.5cm.
- Poor skin to a wound bed the hospital, the -Perform routine - To be able to
turgor causing lesion will be inspections distinguish Long-term:
- Skin is cold to ineffective free from during wound observed During the stay
touch in lower wound healing. infection and care: changes in the hospital of
extremities will not grow to -Irrigate with a - This will clean the patient, the
- Skin is dry and more than 3cm sterile normal the wound patient and his
thin in diameter. saline 3 times a without harming wound was free
- Lesion is found day and Monitor the delicate from infection.
on the right leg, every dressing tissues. The diameter of
distal to the change, the - To monitor if the lesion also
knee. wound, its the intervention did not grow in
- Wound is an diameter, and is effective and diameter from
open-wound that discharge. to identify 3cm.
is red in color, further needs.
with serous - Applying wet - This is to keep Goals are met.
exudate, and to dry sterile the wound clean
with diameter of dressing. and minimize
3cm. cross
contamination.
- Vital signs: BP: For health-
110/70; PR: 119; teaching: -To prevent any
RR: 17; T: 37.4° - Teach patient further
that however complications
small the wound that may happen
is, he should get if ignored.
treatment from
the hospital. - To add more
- Instruct patient fluids in the
to drink plenty of body to make the
water (about 8 blood less stiff.
full glasses or
more) - To help in the
- Emphasize proper
importance of circulation of
proper fit blood
clothing

Dependent:
For infection- With the use of
control: gloves and
- By following proper handling
the wound contaminated
precautions dressings
reduces
likelihood of the
spread of
infection.
- Depending - For the
with the doctor’s treatment of
order for the infection and
administration of
antibiotics prevention of
(Ciprofloxacin complications.
500 mg P.O.)